Stability of Patient Preferences Regarding Life-Sustaining Treatments: DISCUSSION

Posted by James

In this study we explored two questions: (1) what are the life-sustaining treatment preferences of criti­cally ill ICU patients; and (2) are these preferences stable over a one-month period. In regard to the first question, ICU patients expressed a diversity of life-sustaining treatment preferences. Preferences re­garding one treatment did not generalize to other treatments. Furthermore, preferences regarding a particular life-sustaining treatment often changed un­der the markedly different clinical conditions pre­sented in the three scenarios. These findings suggest that patient preferences are difficult to predict. We already know that patient preferences do not appear to be strongly correlated with demographic character­istics or health status measures. Thus, it is not surprising that physicians are inaccurate in predicting patient preferences.

Our data support the need to discuss different life- sustaining treatments. The Office of Technology As­sessment (Congressional Board of the 100th United States Congress) recommends consideration of five treatments: cardiopulmonary resuscitation, mechani­cal ventilation, nutritional support and hydration, dialysis for chronic renal failure, and antibiotic ther­apy. This appears to be a reasonable array of treat­ments in terms of technologic sophistication and invasiveness. However, hospitalization is not included and may be the most important decision for terminally ill patients. An alternative approach to understanding patients’ preferences might be to elicit the health and social conditions in which individuals would not want their lives prolonged.

Previous research suggests that increased familiarity with cardiopulmonary resuscitation, whether due to past experience or education, leads to a decreased desire for this treatment. Although a majority of this study’s participants favored resuscitation, especially in the current health situation, many refused resuscita­tion when it was accompanied by mechanical ventila­tion. Education regarding the potential components of resuscitation may result in more patients’ refusal of cardiopulmonary resuscitation. When obtaining infor­mation about patients’ resuscitation preferences, phy­sicians are encouraged to inform patients about the likelihood of other potentially required measures such as intubation and mechanical ventilation. As a conse­quence, patients may specify acceptance or refusal of select interventions used in resuscitation and these preferences can be incorporated in Do Not Resuscitate (DNR) orders. canadian antibiotics

In contrast to patients who seemed comfortable with withdrawing life-sustaining treatments, a small minority of patients did not want life-prolonging treatments withdrawn under any conditions. This minority may create an uncomfortable dilemma for physicians and society. Physicians are not obligated to administer ineffective treatments. However, some pa­tients may view prolonged life in itself to be of sufficient “benefit” to continue treatment. For these patients, the use of any life-sustaining treatment is not considered “futile,” despite no chance of recovery or discontinuation of the particular treatment without death. Although the principle of autonomy is well accepted, society may not be willing to bear the costs of life prolongation by expensive medical therapies. These questions require public debate and explicit policies.